Table 3 Evidence Rounds session details and follow-up

1. Premedication for non-emergency neonatal intubations (17)

• What are the risks and benefits of using premedication for neonatal intubation?

• What are the risks and benefits of not using premedication?

• What are the most safe and effective premedications to use?

• What is the current practice in other units (national & international)?

• Develop a policy for premedication for non-emergency neonatal intubation.

• It should recommend the following medications:

o Administer remifentanil or fentanyl instead of morphine as it has a more rapid onset and a shorter duration of action

o Administer suxamethonium instead of pancurionium

o Add atropine a preventative, vagolytic agent to prevent bradycardia during intubation

• Arrange with pharmacy to stock medications

• Introduce colour-coded sticky labels to assist staff in ensuring that medications are offered in the correct sequence

• Arrange staff training

• Audit practice

Evidence Rounds identified as the ‘driving force’ for the policy.

The medical recommendations were added as an appendix to the neonatal intubation policy and all staff are required to confirm that they have read and understand the policy.

Colour-coded labels have been introduced.

While there is agreement for the need to audit practice, elective intubation is infrequently performed so an audit of practice has not yet been completed. When it does happen, there are plans to audit elements of each intubation.

2. Timing of umbilical cord clamping (32)

• The impact on delayed resuscitation at delivery

• Should resuscitation begin with the baby still attached to the cord?

• What do the current guidelines say?

• Benefits and risks to term and preterm infants

• Obstetric implications for the mother

• Change discharge sheet to include optimal timing of cord clamping.

• Offer delayed cord clamping (DCC) to preterm infants in addition to term infants which has already been the case.

• Conduct audit to assure compliance with documentation

Staff report a ‘concerted effort’ to offer DCC to preterm infants since Evidence Rounds educational initiative.

Audit conducted - 8 out of 11 babies ≤35/40 at birth were documented as having received DCC from between 30 to 60 s.

Staff report plan to audit preterm infants < 35 weeks every 3 months.

3. Medical management of patent ductus arteriosus (PDA) in preterm infants (20)

• What are the risks and benefits of using medical treatments (specifically indomethacin, paracetamol, ibuprofen) for treating PDA in preterm infants?

• What are the risks and benefits of not using them in this population?

Confirmation that best practice was currently in place which is not to routinely treat asymptomatic cases of PDA.

Create a standard operating procedure (SOP) for management of PDA particularly for junior doctors who frequently rotate into the neonatal intensive care unit (NICU).

In December 2018, a doctor was writing this standard operating procedure using evidence presented during the educational session.

The same doctor was reported to be planning an audit of practice.

4. Antenatal screening for group B Streptococcus (GBS) (32)

• What is the rate of recurrence of GBS?

• What is the optimal timing for screening? General thinking = 35–37 weeks

• What are the long term effects on infants who have been treated with antibiotics for GBS?

• Should women with prolonged SROMs at term (of unknown GBS status) be offered screening?

• Should women be offered a patient information leaflet?

The evidence presented at this educational session highlighted a) the increased risk of early-onset group B Streptococcus (EOGBS) in infants of women with risk factors and b) the existence of strategies (screening or intrapartum antibiotic prophylaxis (IAP)) that could reduce the risk. There was consensus amongst staff that there was a need for action because women with GBS in a previous pregnancy were not being offered either strategy. The recommendations from this session were to offer screening to all women who had GBS in a previous pregnancy and to change the local guideline accordingly.

Audit patient charts regularly.

After this educational session, the Royal College of Obstetricians and Gynaecologists (RCOG) published their Green-top Guideline no.36 Prevention of Early-onset Neonatal Group B Streptococcal Disease [36]. A staff decision was made to follow the RCOG guidance to screen, however the culture medium to screen was not available at the hospital. Therefore, the local guideline was updated to recommend that all pregnant women who had GBS in a previous pregnancy be informed of their increased risk and offered IAP. In this example, the recommendation from Evidence Rounds was not implemented due to an organisational barrier i.e. a lack of screening medium. Nonetheless, Evidence Rounds increased staff awareness of research evidence and local audit data, promoted discussion and increased motivation to change the guideline and clinical practice.

Audit of 10 patient charts each month have confirmed high levels of compliance with change in practice

5. Antenatal steroid use for preterm deliveries less than 37 weeks gestational age (GA) (20)

• At what GA should the corticosteroid be administered?

• Identifying mothers at risk.

• Routine administration to twins or triplets

• When should steroids be repeated?

The consultant dealing with the patient should consider antenatal steroids when there is a risk of preterm birth at a gestational age of 23 weeks + 0 days to 23 weeks + 6 days (previously 24 weeks + 0 days).

Change guideline on preterm premature rupture of the membranes (PPROM) to reflect this.

There was a gap in knowledge of the evidence prior to Evidence Rounds. After the educational session, awareness of the evidence increased and it was discussed at subsequent meetings.

The local guideline was updated and practice changed.

6. Fetal blood sampling (FBS) (27)

• The specificity and sensitivity of FBS.

• Does FBS have any impact on C-sections and instrumental delivery rates?

• Is taking a sample from the fetal scalp a true reflection of fetal well-being?

• The differences between the FIGO and NICE guidelines in interpreting CTG’s and criteria for FBS.

• Normal pH levels of the baby during labour

• FBS in presence of Meconium

• FBS in reducing incidence of HIE/Cerebral palsy.

• CTG monitoring with FBS vs. CTG only without FBS

The evidence presented in this session demonstrated that digital fetal scalp stimulation is effective as a first option in fetal monitoring if a cardiotocography (CTG) trace is pathological. If the fetal heart rate accelerates, the FBS should only be undertaken if the CTG trace is still pathological. This means that FBS procedures, which are more invasive for mother and fetus, will be reduced. Staff to update existing fetal monitoring guideline accordingly.

The local guideline was updated to reflect these recommendations. The implementation team reported an increased awareness of the evidence however, there has been no real practice change. Staff are questioning why, there are education sessions every month and this topic is frequently discussed at caesarean section meetings.